U.S.

C HEMICAL S AFETY AND H AZARD I NVESTIGATION B OARD

INVESTIGATION REPORT

HYDROGEN SULFIDE POISONING

(2 Dead, 8 Injured)

GEORGIA-PACIFIC
Naheola Mill
PENNINGTON, ALABAMA
JANUARY 16, 2002

KEY ISSUES
REACTIVE HAZARD IDENTIFICATION
HYDROGEN SULFIDE SAFETY
EMERGENCY RESPONSE

REPORT NO. 2002-01-I-AL

ISSUE DATE: JANUARY 2003
2
 Abstract

T his investigation report examines a hydrogen sulfide poisoning

incident that occurred on January 16, 2002, at the Georgia-
Pacific Naheola mill in Pennington, Alabama. Two contractors were
killed, and eight were injured. County paramedics reported symp-
toms of hydrogen sulfide exposure. This report identifies the root
and contributing causes of the incident and makes recommendations
on reactive hazard identification, hydrogen sulfide safety, and emer-
gency response.
The U.S. Chemical Safety and Hazard Investigation Board (CSB) is
an independent Federal agency whose mission is to ensure the safety
of workers, the public, and the environment by investigating and
preventing chemical incidents. CSB is a scientific investigative
organization; it is not an enforcement or regulatory body. Established
by the Clean Air Act Amendments of 1990, CSB is responsible for
determining the root and comtributing causes of accidents, issuing
safety recommendations, studying chemical safety issues, and
evaluating the effectiveness of other government agencies involved Information about available
in chemical safety. No part of the conclusions, findings, or recom- publications may be obtained by
mendations of CSB relating to any chemical incident may be admitted contacting:
as evidence or used in any action or suit for damages arising out of U.S. Chemical Safety and Hazard
any matter mentioned in an investigation report (see 42 U.S.C. Investigation Board
§ 412[r][6][G]). CSB makes public its actions and decisions through Office of Prevention, Outreach,
and Policy
investigation reports, summary reports, safety bulletins, safety recom-
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CSB publications may be
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People’s Safety is the Highest Law number PB2003-101293
.

3
4
 Contents

EXECUTIVE SUMMARY................................................................ 9

1.0 INTRODUCTION ............................................................. 19

1.1 Background .......................................................................... 19
1.2 Investigative Process ............................................................. 19
1.3 Georgia-Pacific Naheola Mill ............................................... 19
1.4 Overview of Naheola Mill ................................................... 20
1.4.1 Kraft Process ............................................................ 20
1.4.2 Waste Treatment Process ........................................ 20

2.0 DESCRIPTION OF INCIDENT ........................................ 23

2.1 Background .......................................................................... 23
2.1.1 Sewer Operation ..................................................... 23
2.1.2 Tank Truck Unloading ............................................. 23
2.1.3 Construction Work ................................................. 26
2.2 Incident Description ............................................................. 26
2.3 Incident Response ................................................................ 28

3.0 ANALYSIS OF INCIDENT ................................................ 29

3.1 Good Engineering Practices ................................................. 29
3.2 Principles of Process Safety Management ............................. 30
3.2.1 Reactive Hazard Management ................................ 30
3.2.2 Process Safety Information ....................................... 31
3.2.3 Incident Investigation ............................................... 32
3.3 Hydrogen Sulfide Safety ...................................................... 32
3.4 Emergency Response ........................................................... 34

4.0 REGULATORY ANALYSIS ................................................. 37

4.1 OSHA Process Safety Management ..................................... 37
4.2 Hazard Communication ...................................................... 37
4.3 Hazardous Waste Operations and Emergency Response .... 38

5.0 ROOT AND CONTRIBUTING CAUSES ........................ 39

5.1 Root Causes ......................................................................... 39
5.2 Contributing Causes ............................................................ 39

6.0 RECOMMENDATIONS .................................................... 41

7.0 REFERENCES .................................................................... 45

APPENDIX A: Incident Timeline ................................................... 47

APPENDIX B: Logic Diagram ........................................................ 49

5
Figures

1 Naheola Mill Waste Treatment Process ................................ 21

2 Tank Truck Unloading Station ............................................... 24

3 Collection Drain Next to Tank Truck Unloading Station ....... 24
4 Oil Pit and Adjacent Tank Truck Unloading Station .............. 24

5 Oil Pit Control Valves............................................................. 25

6 Approximate Locations of the 10 Victims .............................. 27

6
 Acronyms and Abbreviations

AFPA American Forest and Paper Association

AIChE American Institute of Chemical Engineers
ANSI American National Standards Institute
ASSE American Society of Safety Engineers
ATSDR Agency for Toxic Substances and Disease Registry
CCPS Center for Chemical Process Safety
CFR Code of Federal Regulations
CPR Cardiopulmonary resuscitation
CSB U.S. Chemical Safety and Hazard Investigation
Board
DHHS U.S. Department of Health and Human Services
DOT U.S. Department of Transportation
EMS Emergency Medical Services
ERT Emergency response team
H 2S Hydrogen sulfide
HAZCOM Hazard Communication Standard (OSHA)
Hazwoper Hazardous Waste Operations and Emergency
Response Standard (OSHA)
IBEW International Brotherhood of Electrical Workers
IChemE Institution of Chemical Engineers
IDLH Immediately dangerous to life or health
MMG Medical Management Guidelines
MOC Management of change
MSDS Material safety data sheet
NaSH Sodium hydrosulfide
NIOSH National Institute of Occupational Safety and Health
OSHA Occupational Safety and Health Administration
PACE Paper, Allied-Industrial, Chemical & Energy
Workers International Union

7
Acronyms and Abbreviations (cont’d)

ppb Parts per billion

ppm Parts per million
PPSA Pulp and Paper Safety Association
PSM Process Safety Management (OSHA)
SCBA Self-contained breathing apparatus
SCT Secretariat of Transport and Communications
(Canada)
TC Transport Canada
U.S.C. United States Code
WTTP Wastewater treatment plant

8
 Executive Summary

ES.1 Introduction
O n January 16, 2002, highly toxic hydrogen sulfide (H2S) gas
leaked from a sewer manway at the Georgia-Pacific Naheola
mill in Pennington, Alabama.1 Several people working near the
manway were exposed to the gas. Two contractors from Burkes
Construction, Inc., were killed. Eight people were injured–seven
employees of Burkes Construction and one employee of Davison
Transport, Inc. Choctaw County paramedics who transported the
victims to hospitals reported symptoms of H2S exposure.
Because of the serious nature of this incident, the U.S. Chemical
Safety and Hazard Investigation Board (CSB) initiated an investiga- . . . the incident that occurred at the
tion to determine the root and contributing causes and to issue Georgia-Pacific Naheola mill is a
recommendations to help prevent similar occurrences. CSB defines reactive chemical incident.
a reactive incident as:
A sudden event involving an uncontrolled chemical reaction–
with significant increases in temperature, pressure, or gas
evolution–that has caused, or has the potential to cause,
serious harm to people, property, or the environment.
Based on this definition, the incident that occurred at the Georgia-
Pacific Naheola mill is a reactive chemical incident.
CSB was assisted in this investigation by the Agency for Toxic
Substances and Disease Registry (ATSDR), an agency of the U.S.
Department of Health and Human Services (DHHS). One of the
key functions of ATSDR is to respond to emergency releases of
hazardous substances that affect public health.

————————–
1
The mill began operation in 1958 as the Marathon Southern Division of the American
Can Company. It was acquired in 1982 by James River Corporation. In 1997, James
River merged with Fort Howard Corporation to form Fort James Corporation. Georgia-
Pacific acquired Fort James Corporation in November 2000. The mill now operates as
Fort James Operating Company, a fully owned subsidiary of Georgia-Pacific Corporation.
This report describes events and history at the Naheola mill and does not necessarily
differentiate among owners.

9
ES.2 Incident
Fifteen tank trucks of NaSH
had unloaded in the 24 hours
prior to the incident.
Burkes Construction employees were working on a construction
project at the Naheola mill in the vicinity of the tank truck unloading
station, where various chemicals could be unloaded. Sodium
hydrosulfide (NaSH) was being unloaded on January 15–16.
The unloading station consists of a large concrete pad sloped to a
collection drain. A shallow concrete pit containing unloading pumps
and associated process piping is located directly next to the pad and
collection drain. This pit–commonly referred to as the oil pit–collects
rainwater, condensate, and occasionally spilled chemicals from the
unloading station. Due to environmental concerns about oil from the
fuel oil pumps getting into the mill effluent, the drain valve from the
oil pit to the acid sewer was locked closed.
The job required Burkes employees to work in or near the oil pit,
which–at the time of the incident on January 16–contained liquid.
Those interviewed estimated that it was typical for approximately 5
gallons of NaSH to collect in the oil pit from various sources (pump
leaking, flushing unloading lines, etc.) during each offloading of a
tank truck.
Fifteen tank trucks of NaSH had unloaded in the 24 hours prior to
the incident. Consequently–though the material in the pit was mainly
water–it also contained NaSH from the unloading of the 15 trucks.
To avoid having the construction crew stand in the fluid-filled pit, an
operator opened a valve to drain the oil pit;2 after 5 minutes, the
valve was closed and relocked.
In the same area, three Davison Transport tank trucks arrived carrying
NaSH. With the assistance of two Georgia-Pacific operators, one of
the truck drivers connected his vehicle to the unloading hose. Wit-
nesses estimated that when the connection was made, up to 5
gallons of NaSH spilled to the collection drain. (The tank truck,
however, was not actually unloaded.)
————————–
2
There was a procedure for periodically checking the oil pit and draining it if necessary.
Although the oil pit was not full, the operator followed procedure when draining the pit.
10
On the day of the incident, sulfuric acid was being added to the acid
sewer to control pH downstream in the effluent area. NaSH from NaSH from the oil pit and
the oil pit and the collection drain drained to the sewer and reacted the collection drain drained
with the sulfuric acid to form H2S. Within 5 minutes, an invisible to the sewer and reacted
cloud of H2S gas leaked through a gap in the seal of a manway in the with the sulfuric acid to form H2S.
area of the Burkes Construction workers. Two contractors near the
manway were killed by H2S poisoning; seven other Burkes employees
and one Davison Transport driver were injured due to H2S expo-
sure.
Seven of the injured contractors were driven in private vehicles to Two contractors near the manway
Thomasville Infirmary in Thomasville, Alabama. Choctaw County were killed by H2S poisoning; seven
Emergency Medical Services (EMS) transported three other victims other Burkes employees and
(including the two fatally injured) to hospitals in Meridian, Mississippi. one Davison Transport driver
The clothing of one victim was completely removed and placed in a were injured due to H2S exposure.
bag; the clothing of the other two victims was not removed.3
The six Choctaw County paramedics who transported the victims
reported symptoms of H2S exposure; however, the two paramedics
who removed the clothes of their patient reported milder symptoms.
All of the County paramedics were medically evaluated and then
released.

ES.3 Key Findings

1. H2S was not identified as a hazard in the immediate area of the
mill where the incident occurred. For this reason, there were no
monitors, alarms, or warning signs in the area.

2. Modifications to the acid sewer over a period of several years

included connections to the chlorine dioxide sewer, to the sewer
from the truck unloading area, and to the containment area
known as the oil pit. When these changes were made, the
chemicals that could be added to the sewer and their interactions
with other chemicals were not identified, nor were formal hazard
evaluations or management of change (MOC) analyses con-
ducted.

————————–
3
The shirt of one victim was removed to facilitate medical procedures.

11

Georgia-Pacific did not require
detailed H2S safety training
for those working in this area
of the mill.
Beginning on the morning of
January 16, sulfuric acid–used
to control the pH of the mill
wastewater–was continuously
added to the acid sewer. . . . the
volume of liquid in the acid sewer
was lower than normal; and,
consequently, the concentration
of acid was high.
No hazard review or MOC analysis
was performed when the oil pit and
the collection drain from the truck
unloading area were connected
to the acid sewer.
3. Georgia-Pacific did not require detailed H2S safety training for
those working in this area of the mill. The contractors working
on the day of the incident had only a basic awareness of H2S
and its hazards.
4. Beginning on the morning of January 16, sulfuric acid–used to
control the pH of the mill wastewater–was continuously added
to the acid sewer. Because the chlorine dioxide unit that emptied
into the sewer line was not running at the time of the incident,
the volume of liquid in the acid sewer was lower than normal;
and, consequently, the concentration of acid was high.
5. During the truck unloading process, several potential sources of
NaSH could leak and drain through the oil pit or collection drain
to the acid sewer–such as material released from connecting and
disconnecting the trucks, from flushing the loading line, or from a
leaking pump seal or packing. In the 24 hours prior to the
incident, 15 tank trucks of NaSH were unloaded, and one was
connected to begin unloading. This activity resulted in NaSH
collecting in the oil pit and draining to the sewer.
6. The manufacturer’s material safety data sheet (MSDS) for NaSH
states that this substance will generate H2S gas if it contacts acid.
For large spills, it recommends that runoff be prevented from
entering sewers or drains.
7. The Naheola mill did not apply the principles of process safety
management to truck unloading or to the acid sewer.4
n Hazard information about NaSH, available on the MSDS,
was not incorporated into mill procedures or training.
n No hazard review or MOC analysis was performed when
the oil pit and the collection drain from the truck unloading
area were connected to the acid sewer.
————————–
4
The principles of process safety management are incorporated into the Occupational
Safety and Health Administration (OSHA) Process Safety Management (PSM) Standard
(29 CFR 1910.119); however, even a facility that is not subject to the OSHA regulation
should apply the good practices of process safety. The NaSH truck unloading area at the
Naheola mill was not part of a process covered by the PSM Standard.
12
8. The manway involved in the incident was originally an unsealed
open grate. The sewer was modified to convert it to a closed
sewer, and the manway was eventually outfitted with a fiberglass
The manway involved
cover and sealed.
in the incident was originally
9. Interviewed employees had observed leaking chlorine dioxide an unsealed open grate.
from the fiberglass manway on previous occasions and recalled
repairs that were sometimes documented by work orders. These
events were not reported as near-miss incidents, nor were the
causes of the leaks formally investigated. The Georgia-Pacific
corporate investigation policy–which requires investigating near- The victims . . . were not
miss incidents, including releases of hazardous materials–was not decontaminated at the scene.
yet in place at the Naheola mill.

10. The victims were removed from the incident scene and taken to
the mill first-aid station prior to setup of the incident command
system. They were not decontaminated at the scene. Mill guide-
lines did not provide for decontamination at the first-aid station.

11. The clothing of one of the three victims transported to hospitals

was removed, which was not the case with the other two men. The ATSDR Medical Management
The six Choctaw County paramedics who evacuated the men Guidelines do not recognize that
from the mill first-aid station reported symptoms consistent with victims . . . [could] pose a medical
H2S exposure. risk to responders.

12. The ATSDR Medical Management Guidelines (MMG) do not

recognize that victims of H2S gas exposure may release H2S,
which can pose a medical risk to responders (ATSDR, 2001).

ES.4 Root Causes

1. Good engineering and process safety practices were not fol-
lowed when joining the drain from the truck unloading station
and the oil pit to the acid sewer.

n Neither the chemicals that could be introduced into the

sewer nor the hazards of their interactions were identified.

13

No formal hazard review or
MOC analysis was conducted
when connecting sewer lines
from the tank truck unloading
and chlorine dioxide areas
to the acid sewer.
Operating procedures . . . did not
warn of the hazard of mixing NaSH
with acids or the hazard of allowing
NaSH to enter sewers.
ES.5 Contributing
Causes
. . . the fiberglass manway was not
appropriately designed to provide
and maintain an airtight seal
on the sewer.
n No formal hazard review or MOC analysis was conducted
when connecting sewer lines from the tank truck unloading
and chlorine dioxide areas to the acid sewer. Consequently,
no scenarios leading to the possible release of H2S were
identified, nor were warning devices placed in the area.
2. There was no management system to incorporate hazard
warnings about mixing sodium hydrosulfide (NaSH) with acid
into process safety information.
n Design information for projects involving NaSH did not
specify the hazard of mixing NaSH with acid.
n Operating procedures for NaSH tank truck unloading and oil
pit operations did not warn of the hazard of mixing NaSH
with acids or the hazard of allowing NaSH to enter sewers.
n Mill personnel were not trained on the specific hazards of
NaSH, such as handling spilled material or keeping it sepa-
rate from acid.
1. The fiberglass manway was not adequately designed or sealed
to ensure that the sewer remained closed.
The manway was originally an open grate. It was modified by
adding a fiberglass cover and sealed. Those interviewed recalled
prior occasions when chlorine dioxide escaped from the fiber-
glass manway; they also recalled repairs that were sometimes
documented in work orders, but these events were not reported
or investigated as incidents. Thorough incident investigation
would have provided an opportunity to recognize that the
fiberglass manway was not appropriately designed to provide and
maintain an airtight seal on the sewer.
2. The injured contractors did not have adequate training to
understand the hazards of hydrogen sulfide (H2S).
H2S training should include specific instruction on the impor-
tance of wearing proper protective equipment prior to attempting
rescue.
14
 ES.6 Recommendations
Georgia-Pacific Corporation
1. Conduct periodic safety audits of Georgia-Pacific pulp and paper
mills in light of the findings of this report. At a minimum, ensure
that management systems are in place at the mills to:

n Evaluate process sewers where chemicals may collect and

interact, and identify potential hazardous reaction scenarios
to determine if safeguards are in place to decrease the
likelihood or consequences of such interactions. Take into
account sewer system connections and the ability to prevent
inadvertent mixing of materials that could react to create a
hazardous condition.
n Identify areas of the mill where hydrogen sulfide (H2S) could
be present or generated, and institute safeguards (including
warning devices) to limit employee exposure. Require that
personnel working in the area are trained to recognize the
presence of H2S and respond appropriately. Update emer-
gency response plans for such areas, to include procedures
for decontaminating personnel exposed to toxic gas.
n Apply good engineering and process safety principles to
process sewer systems. For instance, ensure that hazard
reviews and management of change (MOC) analyses are
completed when additions or changes are made where
chemicals could collect and react in process sewers. (Such
principles may be found in publications from the Center for
Chemical Process Safety [CCPS].)

2. Communicate the findings and recommendations of this report to

the workforce and contractors at all Georgia-Pacific pulp and
paper mills.

15
Georgia-Pacific Naheola Mill

1. Evaluate mill process sewer systems where chemicals may collect

and react to identify potential hazardous reaction scenarios to
determine if safeguards are in place to decrease the likelihood or
consequences of such interactions. Evaluate sewer connections
and ensure that materials that could react to create a hazardous
condition are not inadvertently mixed, and that adequate mitiga-
tion measures are in place if such mixing does occur.

2. Establish programs to comply with recommendations from

manufacturers of sodium hydrosulfide (NaSH) regarding its
handling, such as preventing it from entering sewers because of
the potential for acidic conditions.

3. Establish programs to require the proper design and maintenance

of manway seals on closed sewers where hazardous materials are
present.

4. Identify areas of the plant where hydrogen sulfide (H2S) could be

present or generated, and institute safeguards (including warning
devices) to limit personnel exposure. Institute a plan and proce-
dures for dealing with potential H2S releases in these areas, and
require that anyone who may be present is adequately trained on
appropriate emergency response practices, including attempting
rescue. Require contractors working in these areas to train their
employees on the specific hazards of H2S, including appropriate
emergency response practices.

5. Update the Naheola mill emergency response plan to include

procedures for decontaminating personnel who are brought to
the first-aid station. Include specific instructions for decontami-
nating personnel exposed to H2S so that they do not pose a
secondary threat to medical personnel.

16
 Agency for Toxic Substances
and Disease Registry (ATSDR)
Evaluate and amend as necessary the ATSDR Medical Management
Guidelines to consider the risk to responders posed by the exposure
to victims of high levels of hydrogen sulfide (H2S) gas. Specify
procedures for adequate decontamination. Communicate the results
of this activity to relevant organizations, such as the American Asso-
ciation of Occupational Health Nurses.

Burkes Construction, Inc.

Train your employees on the specific hazards of hydrogen sulfide
(H2S), including appropriate emergency response practices, in areas
where Georgia-Pacific has identified this material as a hazard.

Davison Transport, Inc.

Communicate the findings and recommendations of this report to
those employees who haul or handle sodium hydrosulfide (NaSH).

American Forest and

Paper Association (AFPA)
International Brotherhood of
Electrical Workers (IBEW)
Paper, Allied-Industrial, Chemical &
Energy Workers International Union (PACE)
Pulp and Paper Safety Association (PPSA)
Communicate the findings and recommendations of this report to
your membership.

17
18
 1.0 Introduction

1.1 Background
O n January 16, 2002, hydrogen sulfide (H2S) gas generated in
a sewer leaked from a gap in the seal of a manway at the
Georgia-Pacific Naheola mill in Pennington, Alabama. Several
people working near the manway were exposed to the gas. Two
contractors from Burkes Construction, Inc., were killed. Seven
employees of Burkes Construction and one employee of Davison
Transport, Inc., were injured. The six Choctaw County paramedics
who transported the victims to hospitals reported symptoms consis-
tent with H2S exposure.

1.2 Investigative
The U.S. Chemical Safety and Hazard Investigation Board (CSB)
examined physical evidence at the site, conducted interviews, and
Process
reviewed relevant documents. CSB exercised a Memorandum of
Understanding with the Agency for Toxic Substances and Disease
Registry (ATSDR) to assist in investigating emergency and medical
response to the incident.

1.3 Georgia-Pacific
The Georgia-Pacific Naheola mill is located in Pennington, Alabama,
approximately 125 miles north of Mobile and 150 miles southwest of
Naheola Mill
Birmingham. Pennington is also located 50 miles east of Meridian,
Mississippi.
The mill began operation in 1958 as the Marathon Southern Division
of the American Can Company. It was acquired in 1982 by James
River Corporation. In 1997, James River merged with Fort Howard
Corporation to form Fort James Corporation. Georgia-Pacific
acquired Fort James Corporation in November 2000. The mill now
operates as Fort James Operating Company, a fully owned subsidiary
of Georgia-Pacific Corporation.
The Naheola mill produces over 650,000 tons of paper, paper-
board, and pulp annually. Approximately 1,475 employees work at
the mill. The Paper, Allied-Industrial, Chemical & Energy Workers
International Union (PACE) and the International Brotherhood of
Electrical Workers (IBEW) represent some of the mill employees.

19
1.4 Overview of
Naheola Mill
The pulping liquor is recycled,
and fresh chemicals are occasionally
added to maintain the proper liquor
chemistry. Sodium hydrosulfide is
one of these makeup chemicals.
The overall pH of the effluent is
affected by various mill operations.
If the pH is low, caustic is added
in the wastewater treatment area; if
the pH is high, sulfuric acid is added.
1.4.1 Kraft Process
The Naheola mill uses the kraft process to produce pulp.1 In this
process, wood chips are treated with a liquor that chemically breaks
them down into pulp. Kraft pulping liquor is made up of sodium
hydroxide and sodium sulfide. The pulping liquor is recycled, and
fresh chemicals are occasionally added to maintain the proper liquor
chemistry. Sodium hydrosulfide (NaSH) is one of these makeup
chemicals.
The pulp is bleached using chlorine dioxide, caustic, and oxygen.
The chlorine dioxide is generated onsite. Some of the pulp is dried
and sold as a final product. The remaining pulp is processed prima-
rily into tissue, towels, and paperboard.
1.4.2 Waste Treatment Process
The Naheola mill contains a process sewer network that collects
waste; the process sewers join at a mixing basin in the effluent
treatment area.
The pH2 of the untreated mill effluent is maintained between 7 and
9 to ensure that the waste is efficiently treated. The overall pH of
the effluent is affected by various mill operations. If the pH is low,
caustic is added in the wastewater treatment area; if the pH is high,
sulfuric acid is added.
————————–
1
Pulp is the fibrous material derived from wood. It is the main raw material in making
paper.
2
pH is a measure of the acidity or alkalinity of a solution. It is numerically equal to 7 for
neutral solutions; it increases with decreasing alkalinity and decreases with increasing
acidity.
20
The acid is manually added in a sewer line, commonly referred to as
the acid sewer, which originates in the chemical area where the acid
tank is located (Figure 1). Drainage from the truck unloading station
flows to the acid sewer and mixes with other mill waste streams in
the mixing basin. Wastewater flows from the mixing basin to one of
two clarifiers. The streams from the clarifiers are combined at a lift
Drainage from the truck unloading
station prior to additional treatment and discharge to the Tombigbee
station flows to the acid sewer and
River.
mixes with other mill waste streams
in the mixing basin.

Acid addition

r
e we Truck unloading
s
id
Ac

Various mill streams

Mixing basin

Clarifier Clarifier

Treatment and
Lift station outfall

Figure 1. Naheola mill waste treatment process.

21
22
 2.0 Description of Incident

2.1 Background
2.1.1 Sewer Operation

O n January 16, the pH of the wastewater at the mill effluent

treatment plant was high. To ensure efficient wastewater
treatment and to comply with environmental permits, sulfuric acid
was added to the acid sewer per normal procedure, as described in To ensure efficient wastewater
Section 1.4.2. Acid was continuously added to the sewer on the day treatment and to comply
of the incident; at the same time, the chlorine dioxide generator was with environmental permits, sulfuric
not running, which resulted in a lower than normal flow of water acid was added to the acid sewer
through the sewer. This combination of acid volume and low water per normal procedure . . .
flow accounted for the high concentration of acidic water in the
sewer.

[The] combination of acid volume

and low water flow accounted
2.1.2 Tank Truck Unloading for the high concentration
of acidic water in the sewer.
NaSH3 is used in the kraft process to make up pulping liquors. It is
delivered by tank truck and stored onsite. The Naheola mill may go
several months without a delivery and then bring in several tank
trucks in a short span of time to replenish the supply. NaSH is
delivered to an unloading station located in a typically unoccupied
area near the maintenance shops, between the chemical area and
the wastewater treatment area. Fuel oil and caustic are unloaded in
the same area.
NaSH is delivered to an unloading
The tank truck unloading station (Figure 2) is located on a large
station located in a typically
concrete pad sloped to a collection drain. The drain is routed
unoccupied area near
through two normally open valves (valves 2 and 3) to the acid sewer.
the maintenance shops . . .
The process piping and various unloading pumps are located on a
shallow curbed concrete containment area, directly next to the pad
and collection drain (Figure 3). This area is commonly referred to as
the oil pit (Figure 4).

————————–
The Naheola mill used a solution of 30 percent NaSH in water.
3

23
 Figure 2. Tank truck unloading station.

Figure 3. Collection drain next to

tank truck unloading station.

Figure 4. Oil pit and adjacent tank truck unloading station.

24
The oil pit (with a maximum depth of 20 inches) collects rainwater,
condensate, and incidentally spilled chemicals from the tank truck
unloading station. It is emptied through two valves (see also
Figure 5). The drain valve (valve 1) on the pit is kept closed and locked
The oil pit . . . collects rainwater,
due to environmental concerns about oil getting into the mill effluent;
condensate, and incidentally spilled
valve 3 is kept open. Per procedure, operators periodically inspect the
chemicals from the tank truck
oil pit; if no oil is present, they unlock valve 1 and drain the pit to the
unloading station.
acid sewer.

Figure 5. Oil pit control valves.

In the 24 hours preceding the release

Personnel interviewed estimate that it is typical for approximately of H2S gas, 15 truckloads
5 gallons of NaSH to collect in the oil pit from various sources (pump of NaSH were unloaded
leaking, flushing unloading lines, etc.) during each offloading of a tank and a sixteenth was being prepared
truck. NaSH spilled during hose connections to the truck flows for unloading.
through the collection drain to the acid sewer. Material lost from the
pump or piping during the unloading process accumulates in the oil pit
until drained.
At the time of the January 16 incident, the mill was replenishing its
NaSH inventory. In the 24 hours preceding the release of H2S gas,
15 truckloads of NaSH were unloaded and a sixteenth was being
prepared for unloading.

Burkes Construction was contracted
to replace supports on an overhead
piperack located near the fiberglass
manway . . .
2.2 Incident
Description
. . . the Burkes Construction
employees . . . were standing
on level ground in an open area
adjacent to the tank truck unloading
station, near the fiberglass manway.
2.1.3 Construction Work
Burkes Construction was contracted to replace supports on an
overhead piperack located near the fiberglass manway; the piperack
crossed over the tank truck unloading station and the oil pit, as
shown in Figure 2. As the supports were removed, they were placed
on the side of the road, directly in front of the manway.4 On the day
of the incident, the contractors were working in the area of the tank
truck unloading station.
At approximately 3:15 pm on January 16, the Burkes Construction
employees finished their afternoon break and prepared to return to
work (see the timeline in Appendix A). They were standing on level
ground in an open area adjacent to the tank truck unloading station,
near the fiberglass manway.
The piperack work required some Burkes employees to be in or near
the oil pit, which contained liquid at the time; the material was
primarily water and NaSH that had collected during unloading of
the 15 tank trucks.5
The Burkes contractors asked a Georgia-Pacific operator to drain the
oil pit. After inspecting for oil, the operator opened valve 1; the pit
drained for approximately 5 minutes, and then the valve was closed.
Meanwhile, with the assistance of two Georgia-Pacific operators, the
Davison truck driver connected his vehicle to the unloading hose.
Witnesses estimated that when the connection was made, up to 5
gallons of NaSH spilled to the collection drain. Unloading had not
actually begun.
————————–
4
There is a possibility that one of the supports contacted the manway and compromised
its seal.
5
Those interviewed estimated that–during the unloading process–it is typical for up to 5
gallons of NaSH to collect in the oil pit from various sources (i.e., pump leaking, flushing
unloading lines, etc.).
26
Also on the same day, sulfuric acid was being added to the acid
sewer to control pH downstream in the effluent area. The NaSH The NaSH draining to the acid sewer
draining to the acid sewer from the oil pit and the collection drain from the oil pit and
around the truck unloading station reacted with sulfuric acid (present the collection drain . . . reacted
in the sewer) to form H2S. with sulfuric acid (present in the
Within 5 minutes of the material draining from the oil pit and sewer) to form H2S.
collection drain to the acid sewer, an invisible cloud of highly toxic
H2S gas leaked through a gap in the seal of the manway near the
Burkes Construction workers. Three contractors (A, B, and C in
Figure 6) were immediately overcome by H2S and fell down. An- Within 5 minutes of the material
other contractor (D) passed out as he rushed to aid a coworker (A). draining . . . to the acid sewer,
Simultaneously, one contractor (I) left the area, and four others (E, F, an invisible cloud of highly toxic
G, and H) walked to fresh air. One of these men (F) passed out H2S gas leaked through a gap
momentarily before he and another contractor (E) realized that their in the seal of the manway . . .
coworkers had fallen; the two returned to the area to assist in remov-
ing the others to fresh air. Contractor (F) passed out a second time
while attempting to assist his coworkers. Georgia-Pacific operators
working in the vicinity of the NaSH tank truck saw the Burkes
employees falling and went to the control room to report the Two Burkes employees
incident. in the immediate area
of the manway were killed.
Two Burkes employees (B and C) in the immediate area of the
manway were killed. Seven other Burkes employees and one
Davison truck driver (J) were injured.

Figure 6. Approximate locations of the 10 victims (“A” through “J”).

27
2.3 Incident
Response
The injured were not
decontaminated at the scene
or at the first-aid station.
The six paramedics who transported
the victims to hospitals . . . all
described a strong odor in the
ambulance bays.
Two of the paramedics reported less
severe exposure symptoms–probably
because their patient was exposed
to a lower level of H2S and his
clothing had been removed.
————————–
6
The mill first-aid station is located near the front gate of the mill, a considerable distance
from the incident scene.
7
The fourth ambulance remained at the scene on standby and did not transport patients.
The injured Burkes employees assisted each other and carried their
fatally injured coworkers from the area closest to the release, as
described in Section 2.2. The mill emergency response team (ERT)
was notified. Others who came to the area performed cardiopulmo-
nary resuscitation (CPR) on the two fatally injured men, who were
transferred by mill ambulance to the first-aid station.6
The other injured personnel were transported by pickup trucks and
motorized carts. The injured were not decontaminated at the scene
or at the first-aid station. The incident commander arrived shortly
after the victims had left the scene. He and the ERT evacuated the
area, began search/rescue, set up zones, and began air monitoring.
Four Choctaw County ambulances–staffed with two paramedics
each–arrived at the mill first-aid station. Two ambulances trans-
ported the fatally injured men, and a third ambulance transported the
injured truck driver.7 Two victims were taken to Rush Hospital and
one to Riley Hospital, both located in Meridian, Mississippi, a 45-
minute drive. Burkes and Georgia-Pacific employees transported the
other injured Burkes employees to nearby Thomasville Infirmary,
where six were admitted and one was sent to a hospital in Mobile
because of a previous heart condition.
The six paramedics who transported the victims to hospitals in
Meridian all described a strong odor in the ambulance bays. They
opened windows and turned fans on to reduce the odor. After
delivering the victims to the hospitals, the paramedics reported
symptoms consistent with H2S exposure. They were medically
evaluated and released.
Two of the paramedics reported less severe exposure symptoms–
probably because their patient was exposed to a lower level of H2S
and his clothing had been removed.
28
 3.0 Analysis of Incident

3.1 Good Engineering

T he sewer line from the oil pit to the acid sewer was installed as
part of a project to direct water from various storage pits to a
process sewer. The work was completed in 1995 when the mill
Practices

was owned by James River Corporation.

CSB did not find any procedures that described the engineering
process. However, the James River capital appropriations request
There was no detailed information
contained a Project Impact Statement checklist. The checklist asked
on chemicals that could be present
general safety and environmental questions, focusing mainly on
in the oil pit and drain
regulatory compliance. There was no detailed information on
to the acid sewer–nor was there
chemicals that could be present in the oil pit and drain to the acid
a management of change analysis
sewer–nor was there a management of change (MOC) analysis or
or formal hazard review.
formal hazard review.8
The NaSH material safety data sheet (MSDS) and manufacturer’s
information explain the hazards of NaSH and state that its interaction
with acid will produce H2S. For large spills, it recommends that
runoff be prevented from entering sewers or drains. Another NaSH The NaSH material safety data sheet
manufacturer’s product literature cautions against allowing NaSH to and manufacturer’s information
drain to sewers because their contents are often acidic. If James explain the hazards of NaSH and state
River had identified the chemicals that could potentially drain to the that its interaction with acid
acid sewer and completed a proper hazard review, it would likely will produce H2S.
have realized the risk of allowing NaSH to enter the sewer.
Drawings of the new sewer connections were made for construc-
tion. However, it was not James River’s practice to update overall
mill sewer drawings to reflect modifications. Therefore, at the time
of the incident, no drawing of the mill sewer system accurately If James River [Corporation] had
portrayed its layout. identified the chemicals that could
Good engineering practices during the conceptual design phase of a potentially drain to the acid sewer and
capital project such as this include identifying all chemicals that could completed a proper hazard review, it
be directed to the sewer, their hazards, and the hazards of their would likely have realized the risk
interactions.9 The design information found for this project did not of allowing NaSH to enter the sewer.
list NaSH or other substances that collected in the oil pit and could

————————–
8
A hazard review is a systematic process to investigate hazards, assess potential conse-
quences, and establish a design and operating basis for safety.
9
The American Institute of Chemical Engineers (AIChE) Center for Chemical Process
Safety (CCPS) describes good engineering practices for various phases of a capital project
(CCPS, 1989).

29

The design information found
for this project did not list NaSH
or other substances that collected
in the oil pit and could enter
the acid sewer.
enter the acid sewer. Identification of the chemicals and their
hazards, and a proper hazard review, would have identified
the likely consequences and also the modifications required to
eliminate or control the hazard. The Naheola mill did not
follow these practices.
Process sewers are an integral part of a waste collection, treat-
ment, and disposal process that presents unique hazards.
Additionally, the various effluents collected present their own
hazards (e.g., mixing and cross-reactions). There is consider-
able documentation of incidents that have occurred in sewers
and drains. Appropriate techniques used for other chemical
processes should also be applied to the design and hazard
evaluation of process sewers (Lees, 1996; CCPS, 1995; Kletz,
1999).

3.2 Principles of
Process Safety Process safety management is the application of management systems
to control hazards and to ensure the safety of a process. The use of
Management such systems is considered good practice for handling chemical
processes.10

The inadvertent mixing

of incompatible chemicals is not
uncommon. However, the Naheola
mill had no formal reactive hazard
management system to identify and
control reactive hazards.
3.2.1 Reactive
Hazard Management
NaSH from the tank truck unloading station was released to the acid
sewer, where it inadvertently reacted with sulfuric acid to produce
H2S. The inadvertent mixing of incompatible chemicals is not
uncommon. However, the Naheola mill had no formal reactive
hazard management system to identify and control reactive hazards.

————————–
10
The principles of process safety management are incorporated into the Occupational
Safety and Health Administration (OSHA) Process Safety Management (PSM) Standard (29
CFR 1910.119); however, even a facility that is not subject to the OSHA regulation should
apply the good practices of process safety management.

30
The first step in a reactive hazard management program is to deter-
mine whether a material has reactive hazards (CCPS, 2001). Reac-
tive hazard information is found in literature and on some MSDSs.
The MSDS collected by the mill
The MSDS collected by the mill from its NaSH supplier indicated
from its NaSH supplier indicated that
that this substance readily reacts with acid to form H2S–which clearly
this substance readily reacts with acid
indicates a potential reactive hazard.
to form H2S–which clearly indicates
After the identification of a reactive hazard, precautions should be a potential reactive hazard.
taken to mitigate the hazard. If such precautions were in place at the
Naheola mill, the oil pit containing NaSH would likely not have been
tied into the acid sewer.

If [mitigative measures] were in place

3.2.2 Process Safety Information at the Naheola mill, the oil pit
containing NaSH would likely not
The NaSH MSDS contains warnings about the hazards of combin- have been tied into the acid sewer.
ing NaSH solution with acid. It notes that the reaction will produce
toxic H2S. The MSDS also specifies that large spills should be
cleaned up using absorbent material, and that the substance should
be prevented from entering sewers or natural waterways. Addition-
ally, it notes that the headspace of a tank truck could contain H2S
vapors that evolve from the solution. The NaSH MSDS was avail-
able in the control room and at the tank truck unloading station. Although the [chemical approval]
The mill used a chemical approval form to collect information on all form for NaSH contained information
chemicals brought onsite. Although the form for NaSH contained about its hazards, none of
information about its hazards, none of this information was incorpo- this information was incorporated
rated into operating procedures or training. Process safety informa- into operating procedures or training.
tion should be incorporated into policies, procedures, and programs.
(CCPS, 1995b) Had this been done, employees would likely have
understood the hazards of NaSH, including the manufacturer’s
recommendation that spills be cleaned up with absorbent material
instead of being washed into a sewer.

31

Interviewed employees reported prior
instances of chlorine dioxide leaking
from the manway involved
in the January 16 incident. . . .
however, these events were not
reported as incidents or investigated.
Because of the design of the sewer,
maintenance personnel were unable
to ensure that the manway was
adequately sealed even
after repairing it.
3.3 Hydrogen
Sulfide Safety
The majority of fatalities associated
with H2S exposure occur in confined
spaces . . . In this case, however,
the H2S poisoning occurred
in a flat unconfined area.
11
gas. Breathing air containing chlorine dioxide gas may cause nose, throat, and lung
irritation.
12
3.2.3 Incident Investigation
Incident investigation is an important element of a safety management
system. It allows companies to assess and correct underlying causes
of near misses and accidents (CCPS, 1989). Georgia-Pacific has a
corporate policy for investigating incidents.
Interviewed employees reported prior instances of chlorine dioxide11
leaking from the manway involved in the January 16 incident. Some
employees recalled repairs, and at least some of these were docu-
mented by work orders to reseal the manway; however, these events
were not reported as incidents or investigated. The Georgia-Pacific
corporate incident investigation policy–which requires investigation
of near-miss incidents, including releases of hazardous materials–had
not yet been put in place at the Naheola mill.
Because of the design of the sewer, maintenance personnel were
unable to ensure that the manway was adequately sealed even after
repairing it. If earlier incidents had been investigated, it is likely that
management would have determined that the manway required
design modification.
H2S is a colorless, extremely flammable toxic gas. Although it has a
characteristic “rotten egg” odor detectable at concentrations as low
as 0.5 part per billion (ppb), olfactory fatigue12 occurs rapidly and at
low concentrations. Exposure to concentrations of 500 parts per
million (ppm) causes loss of consciousness, and exposure to concen-
trations as high as 700 ppm can cause immediate death.
The majority of fatalities associated with H2S exposure occur in
confined spaces, such as sewers, waste dumps, sludge plants, tanks,
and cesspools (ATSDR, 1999). In this case, however, the H2S
————————–
Employees identified chlorine dioxide by its color; it is a greenish-yellow manufactured
Olfactory fatigue refers to cessation of the sense of smell.
32
poisoning occurred in a flat unconfined area. When identifying
areas with potential H2S hazards, both confined and unconfined
spaces should be considered. According to ATSDR, the men
According to ATSDR, the men who died were likely exposed to H2S who died were likely exposed
concentrations greater than 700 ppm. The injured victims were to H2S concentrations
exposed to lower, but still dangerous, concentrations. Some of the greater than 700 ppm.
injured reported smelling an odor for an instant, but then their sense
of smell was deadened.
H2S was not identified as a hazard in the typically unoccupied area
where the incident occurred. There were no monitors or alarms to
warn of a release. Personnel had only their sense of smell to indicate H2S was not identified as a hazard
the possible presence of H2S; however, smell is not a reliable indica- in the typically unoccupied area where
tor because the gas causes olfactory fatigue. the incident occurred. . . . Personnel
had only their sense of smell
The Burkes employees had a general awareness of H2S. More to indicate [its] possible presence . . .
detailed safety training would have covered how to identify H2S however, smell is not a reliable
and how to respond in an emergency. Emergency training should indicator because the gas causes
instruct individuals to leave the area and not to attempt rescue of olfactory fatigue.
others unless they themselves are trained and wearing the proper
protective equipment.
Per Georgia-Pacific policy, Burkes construction workers wore the
Scott Speed Evac disposable mouth bit respirator (model 90 AG) on
their belts and were trained in its use. These respirators are used for
Emergency training should instruct
escape in situations where unexpected releases result in atmospheres
individuals to leave the area and not
containing low levels of chlorine, chlorine dioxide, sulfur dioxide,
to attempt rescue of others unless
H2S, or hydrogen chloride. They are not intended for use in imme-
they themselves are trained and
diately dangerous to life or health (IDLH) atmospheres.
wearing the proper protective
Several Burkes employees tried to use the respirators, but H2S levels equipment.
were too high for the equipment to be effective. Only a self-
contained breathing apparatus (SCBA) would have provided ad-
equate protection at the exposure levels present on January 16.
The Naheola mill did not adequately identify areas that contain–or
have the potential to contain–dangerous levels of H2S gas. All areas
of H2S hazard should have been identified; and personnel, including
contractors, should have been trained on how to respond in the
event of an H2S release.

33
3.4 Emergency
Response
The mill ambulance arrived
at the scene and removed the injured
prior to arrival of the incident
commander. Mill personnel did not
remove the victims’ clothing at the
first-aid station because there was
no visible contamination.
Paramedics were initially told that
the victims had been exposed to either
chlorine dioxide or H2S. . . . [They]
had only the [DOT] Emergency
Response Guidebook to refer to
for treatment of these chemical
exposures.
————————–
13
Nurses.
Injured personnel were not decontaminated–neither at the scene of
the incident nor at the mill first-aid station. The mill’s emergency
response plan contains procedures for decontamination, but it is a
function of the incident command system. The mill ambulance
arrived at the scene and removed the injured prior to arrival of the
incident commander. Mill personnel did not remove the victims’
clothing at the first-aid station because there was no visible contami-
nation.
At the first-aid station, mill personnel continued to aid the victims until
the Choctaw County Emergency Medical Services (EMS) team
arrived. The first-aid station was staffed by five registered nurses13
who provided 24-hour coverage; two nurses were on duty at the
time of the incident. When the County paramedic units arrived at
the mill, they took over treatment of the most critical victims.
The first Choctaw County ambulance arrived 3 to 5 minutes after
being notified (and 19 minutes after the incident began). Paramedics
were initially told that the victims had been exposed to either chlorine
dioxide or H2S. The victims were treated for their symptoms.
The responding paramedics had only the Emergency Response
Guidebook (DOT/TC-SCT, 2000) to refer to for treatment of these
chemical exposures. This guidebook is intended to be used by first
responders to hazardous material transportation incidents. It contains
only cursory information on first aid and decontamination, and
advises that contaminated clothing and shoes be removed. The two
paramedic teams that did not remove the victims’ clothing stated that
they saw no obvious signs of contamination.
The six paramedics stated that during the 40- to 50-minute trips to
hospitals, they noticed a strong odor and opened the vehicle win-
dows and turned on the exhaust fans. The paramedic team trans-
porting the truck driver initiated decontamination of the victim by
removing his clothing.
The plant nurses are members of the American Association of Occupational Health
34
Each of the paramedics was evaluated for symptoms of H2S expo-
sure, including burning throat and eyes and nausea. The paramedic Each of the paramedics was evaluated
team that removed the truck driver’s clothing had less severe symp- for symptoms of H2S exposure,
toms than the other two crews. Collectively, the paramedics may including burning throat and eyes and
have experienced fewer symptoms if the clothes of all the victims had nausea. The paramedic team that
been removed at the scene or at the first-aid station. removed the truck driver’s clothing
The paramedics did not have hazardous material training, nor were had less severe symptoms than
they trained on use of the Emergency Response Guidebook (DOT/ the other two crews.
TC-SCT, 2000)–though they did refer to it. The paramedics should
have received more detailed information on H2S at the scene.
The ATSDR Medical Management Guidelines (MMG) were de-
signed for emergency medical personnel (ATSDR, 2001); however,
The ATSDR Medical Management
the responders were not aware of this guidance at the time of the
Guidelines . . . [state] that responders
incident. The MMG on H2S exposure states that responders are
are not at risk when they assist
not at risk when they assist a victim of H2S gas exposure.
a victim of H2S gas exposure.
However, H2S is released from the clothing and skin, and via gas
that expires from the lungs. The threat to responders may be greater
when the situation occurs in a confined space, such as an ambu-
lance. Through its participation in this investigation, ATSDR has
concluded that persons who are exposed to elevated levels of H2S
(i.e., greater than 500 ppm) may pose a threat to responders who . . . H2S is released
come into contact with them. from the clothing and skin, and
via gas that expires from the lungs.

ATSDR has concluded that persons

who are exposed to elevated levels
of H2S (i.e., greater than 500 ppm)
may pose a threat to responders . . .

35
36
 4.0 Regulatory Analysis

4.1 OSHA Process

T he OSHA PSM Standard (29 CFR 1910.119) is intended to
prevent or minimize the consequences of a catastrophic release
of toxic, reactive, flammable, or explosive chemicals. Paper mills are
Safety Management

not exempt from the standard, which applies to processes14 contain-

ing more than a threshold quantity of any one of 137 OSHA-listed
highly hazardous chemicals or substances classified by OSHA as OSHA lists H2S as a highly
flammable. Substances are listed based on their toxic or reactive hazardous chemical; NaSH
properties. OSHA lists H2S as a highly hazardous chemical; NaSH is not listed in the PSM Standard.
is not listed in the PSM Standard.
The PSM Standard covers certain processes at the Naheola mill;
however, the area where the incident occurred was not part of a
PSM-covered process. Although OSHA lists H2S as a highly
hazardous chemical, it is not present in sufficient quantities15 or–in
this case–is not part of an OSHA-defined covered process. There . . . the area where the incident
were no other OSHA PSM highly hazardous chemicals in the area of occurred was not part
the release. of a PSM-covered process.
The Naheola mill applied the site process safety management plan
only to areas of the facility that were covered by the PSM Standard.
Section 3.2 discusses the elements of a process safety management
program that are causally related to this incident.

4.2 Hazard
The OSHA Hazard Communication (HAZCOM) Standard (29
CFR 1910.1200) requires companies to provide their employees
Communication
with information on the hazardous chemicals to which they may be
exposed.
If the good engineering and process safety management practices
outlined in Section 3.0 had been followed, mill personnel would
likely have determined that H2S could possibly be present at the
location of the incident. Good practice would have required the

————————–
14
OSHA defines a process as any activity involving a highly hazardous chemical,
including any use, storage, manufacturing, handling, or onsite movement of such
chemicals, or any combination of these activities.
15
The threshold quantity for H2S is 1,500 pounds.

37
 communication of H2S hazards to Naheola mill employees; similarly,
Burkes Construction would have to communicate the hazards of H2S
to its employees. The HAZCOM Standard requires that this be
done by a formal communication program, to include labels, MSDSs,
and training.

4.3 Hazardous Waste

Operations and The OSHA Hazardous Waste Operations and Emergency Response
(Hazwoper) Standard (29 CFR 1910.120) details requirements for
Emergency Response emergency response activities associated with the release of hazard-
ous substances. The Naheola mill is subject to Hazwoper require-
ments; among other things, the standard mandates specific emer-
gency response training.
The Hazwoper Standard allows for an exemption if employees will
be evacuated in the event of a release, which applies to Burkes
Construction. Accordingly, it was not bound to meet the Hazwoper
requirements.

38
 5.0 Root and Contributing Causes

5.1 Root Causes

1. Good engineering and process safety practices were not fol-
lowed when joining the drain from the truck unloading station
and the oil pit to the acid sewer.

n Neither the chemicals that could be introduced into the

sewer nor the hazards of their interactions were identified.
Neither the chemicals that could
n No formal hazard review or MOC analysis was conducted be introduced into the sewer nor
when connecting sewer lines from the tank truck unloading the hazards of their interactions
and chlorine dioxide areas to the acid sewer. Consequently, were identified.
no scenarios leading to the possible release of H2S were
identified, nor were warning devices placed in the area.

2. There was no management system to incorporate hazard

warnings about mixing sodium hydrosulfide (NaSH) with acid
into process safety information. Personnel were not trained
on the specific hazards of NaSH,
n Design information for projects involving NaSH did not such as handling spilled material or
specify the hazard of mixing NaSH with acid. keeping it separate from acid.
n Operating procedures for NaSH tank truck unloading and oil
pit operations did not warn of the hazards of mixing NaSH
with acids or the hazards of allowing NaSH to enter sewers.
n Personnel were not trained on the specific hazards of NaSH,
such as handling spilled material or keeping it separate from
acid.

5.2 Contributing
1. The fiberglass manway was not adequately designed or sealed
to ensure that the sewer remained closed.
Causes
The manway was originally an open grate. It was modified by
adding a fiberglass cover and sealed. Those interviewed recalled Those interviewed recalled prior
prior occasions when chlorine dioxide escaped from the fiber- occasions when chlorine dioxide
glass manway; they also recalled repairs that were sometimes escaped from the fiberglass manway
documented in work orders, but these events were not recorded . . . but these events were not
or investigated as incidents. Thorough incident investigation recorded or investigated as incidents.
would have provided an opportunity to recognize that the

39

H2S training should include specific
instruction on the importance
of wearing proper protective
equipment prior to attempting rescue.
fiberglass manway was not appropriately designed to provide and
maintain an airtight seal on the sewer.
2. The contractors injured during the incident did not have ad-
equate training to understand the hazards of hydrogen sulfide
(H2S).
H2S training should include specific instruction on the impor-
tance of wearing proper protective equipment prior to attempting
rescue.
40
 6.0 Recommendations

Georgia-Pacific
1. Conduct periodic safety audits of Georgia-Pacific pulp and paper Corporation
mills in light of the findings of this report. At a minimum, ensure
that management systems are in place at the mills to:

n Evaluate process sewers where chemicals may collect and

interact, and identify potential hazardous reaction scenarios
to determine if safeguards are in place to decrease the
likelihood or consequences of such interactions. Take into
account sewer system connections and the ability to prevent
inadvertent mixing of materials that could react to create a
hazardous condition. (2002-01-I-AL-R1)
n Identify areas of the mill where hydrogen sulfide (H2S) could
be present or generated, and institute safeguards (including
warning devices) to limit personnel exposure. Require that
personnel working in the area are trained to recognize the
presence of H2S and respond appropriately. Update emer-
gency response plans for such areas to include procedures
for decontaminating personnel exposed to toxic gas.
(2002-01-I-AL-R2)
n Apply good engineering and process safety principles to
process sewer systems. For instance, ensure that hazard
reviews and management of change (MOC) analyses are
completed when additions or changes are made where
chemicals could collect and react in process sewers. (Such
principles may be found in publications from the Center for
Chemical Process Safety [CCPS].) (2002-01-I-AL-R3)

2. Communicate the findings and recommendations of this report to

the workforce and contractors at all Georgia-Pacific pulp and
paper mills. (2002-01-I-AL-R4)

Georgia-Pacific
1. Evaluate mill process sewer systems where chemicals may collect
Naheola Mill
and react to identify potential hazardous reaction scenarios to
determine if safeguards are in place to decrease the likelihood or
consequences of such interactions. Evaluate sewer connections

41
 and ensure that materials that could react to create a hazardous
condition are not inadvertently mixed, and that adequate mitiga-
tion measures are in place if such mixing does occur.
(2002-01-I-AL-R5)

2. Establish programs to comply with recommendations from

manufacturers of sodium hydrosulfide (NaSH) regarding its
handling, such as preventing it from entering sewers because of
the potential for acidic conditions. (2002-01-I-AL-R6)

3. Establish programs to require the proper design and maintenance

of manway seals on closed sewers where hazardous materials are
present. (2002-01-I-AL-R7)

4. Identify areas of the plant where hydrogen sulfide (H2S) could be

present or generated, and institute safeguards (including warning
devices) to limit personnel exposure. Institute a plan and proce-
dures for dealing with potential H2S releases in these areas, and
require that anyone who may be present is adequately trained on
appropriate emergency response practices, including attempting
rescue. Require contractors working in these areas to train their
employees on the specific hazards of H2S, including appropriate
emergency response practices. (2002-01-I-AL-R8)

5. Update the Naheola mill emergency response plan to include

procedures for decontaminating personnel who are brought to
the first-aid station. Include specific instructions for decontami-
nating personnel exposed to H2S so that they do not pose a
secondary exposure threat to medical personnel.
(2002-01-I-AL-R9)

Agency for Toxic

Substances and Evaluate and amend as necessary the ATSDR Medical Management
Guidelines to consider the risk to responders posed by exposure to
Disease Registry victims of high levels of hydrogen sulfide (H2S) gas. Specify proce-
(ATSDR) dures for adequate decontamination. Communicate the results of
this activity to relevant organizations, such as the American Associa-
tion of Occupational Health Nurses. (2002-01-I-AL-R10)

42
 Burkes Construction, Inc.
Train your employees on the specific hazards of hydrogen sulfide
(H2S), including appropriate emergency response practices, in areas
where Georgia-Pacific has identified this material as a hazard.
(2002-01-I-AL-R11)

Davison Transport, Inc.

Communicate the findings and recommendations of this report
to those employees who haul or handle sodium hydrosulfide
(NaSH). (2002-01-I-AL-R12)

American Forest and

Communicate the findings and recommendations of this report Paper Association (AFPA)
to your membership. (2002-01-I-AL-R13)

International
Communicate the findings and recommendations of this report Brotherhood of
to your membership. (2002-01-I-AL-R14)
Electrical Workers (IBEW)

Paper, Allied-Industrial,
Communicate the findings and recommendations of this report Chemical & Energy
to your membership. (2002-01-I-AL-R15)
Workers International
Union (PACE)

Pulp and Paper

Communicate the findings and recommendations of this report Safety Association (PPSA)
to your membership. (2002-01-I-AL-R16)

43
By the
U.S. CHEMICAL SAFETY AND HAZARD INVESTIGATION BOARD

Carolyn W. Merritt
Chair

John S. Bresland
Member

Gerald V. Poje, Ph.D.

Member

Isadore Rosenthal, Ph.D.

Member

Andrea Kidd Taylor, Dr. P.H.

Member

November 20, 2002

44
 7.0 References

Agency for Toxic Substances and Disease Registry (ATSDR), 2001.

Managing Hazardous Material Incidents (MHMI), Volume III,
U.S. Department of Health and Human Services (DHHS),
Public Health Service.

ATSDR, 1999. Toxicological Profile for Hydrogen Sulfide, DHHS,

Public Health Service.

American National Standards Institute, Inc. (ANSI), 2001. American

National Standard Accepted Practices for Hydrogen Sulfide
(H2S) Safety Training Programs, ANSI/ASSE Z390.1-1995
(R2001), American Society of Safety Engineers, May 8, 2001.

Center for Chemical Process Safety (CCPS), 1995a. Guidelines for

Safe Storage and Handling of Reactive Materials, American
Institute of Chemical Engineers (AIChE).

CCPS, 1995b. Process Safety Documentation, AIChE.

CCPS, 1989. Guidelines for Technical Management of Chemical

Process Safety, AIChE.

Kletz, Trevor, 1999. Hazop and Hazan, Fourth Edition, Institution

of Chemical Engineers (IChemE).

Lees, Frank, 1996. Loss Prevention in the Process Industries, Reed

Educational and Professional Publishing Ltd.

National Institute for Occupational Safety and Health (NIOSH),

1977. Criteria for a Recommended Standard, Occupational
Exposure to Hydrogen Sulfide, U.S. Department of Health,
Education, and Welfare, Public Health Service, May 1977.

U.S. Department of Transportation (DOT)/Transport Canada (TC)-

Secretariat of Transport and Communications (SCT, 2000).
2000 Emergency Response Guidebook.

45
46
 APPENDIX A: Incident Timeline

Jan 16
Jan 14 - 16
Jan 15 - 16 ~ 3 pm
Sulfuric acid added to acid sewer
Fifteen trucks of NaSH unloaded Burkes workers take afternoon
to control pH at clarifier
break

Jan 16
Jan 16
~ 3:15 PM GP operator drains oil pit
~ 3 pm
Burkes workers return from for 3-5 minutes
NaSH truck positioned to unload
break

Jan 16
Jan 16
~ 3:20 pm
NaSH truck connected to ~ 3:30 pm
Worker begins to feel
unloading hose Mill first aid receives call; mill
nauseous and some
ERT paged
workers fall down

Jan 16 Jan 16
~ 3:33 pm ~ 3:39 pm
Choctaw County EMS receives Victims arrive at mill first-aid
call and dispatches ambulance station

47
48
 APPENDIX B: Logic Diagram

People killed and

injured

Dangerous Extended exposure

concentration of due to assisting
People working H2S released coworkers
in area

Acid and NaSH Manway not sealed

react in sewer to properly
form H2S

Manway not designed

Oil pit containing NaSH from the to be sealed;
unloading pad drained Acid added to Past gas
NaSH drained to homemade remedies
to acid sewer acid sewer releases not
sewer used
formally
investigated

B D

Hazards of sending No analysis

NaSH to acid Oil pit and pad done when
sewer not realized Initial design sewers
needed to drain
was open sewer combined
to closed sewer

Known hazards
No hazard of NaSH not Chemicals not
analysis incorporated into identified
procedures during project
training, etc.

49
 Extended exposure
A due to assisting
coworkers

H2S training
insufficient

Potential H2S hazard

in area not realized

No
hazard
analysis

50
 Oil pit containing
B NaSH drained to
sewer

Procedure was to drain Sewer from oil pit was NaSH from unloading
Contractors pit after inspecting for joined with acid sewer lines and pump
need to oil during another project collected in pit
stand in pit

Hazards of Material drained from

Pump seal leaking
Environmental NaSH not unloading line
restrictions on incorporated
sending oil to into procedures,
effluent training, etc.

No work order
Hazards of Hazards of
written to repair
NaSH not NaSH not
pump
incorporated incorporated
into procedures, into procedures,
training, etc. training, etc.

Hazards of
Pump NaSH not Pump repair
infrequently incorporated not difficult
used into procedures,
training, etc.

51
D Acid added
to acid sewer

No system to add acid

at clarifiers
pH in clarifier
was high

Acidic material
routinely in No analysis
sewer; adding Acid available in
when sewers
acid manually chemical area
combined
was past
practice

52